Engaging Difficult Patients & Families

1. Engaging Difficult Patients & Families Finding Change with Primary Care Thomas W. Bishop, PsyD Department of Family Medicine

2. Disclosure Statement of Financial Interest I, Thomas W. Bishop, Psy.D. DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

3. Overview • Discuss the contrast between engagement and intervention. • Setting things up for success in therapy. • Touching on Stage of Change with attention to “where do we go?” • Thoughts on engaging parents. • The art and mechanics of child/adol focused therapy. • A nod to the potential role of positive psychology.

4. The Engagement Level of Intervention Engagement of Pt’s & Families in Participating in Interventions Specific Interventions

5. The Practice of Family Systems Family Staff • Common Tasks (Family & Staff) • Soothe • Develop Trust • Manage Conflict • Consultation Directives • Join • Focus • Promote Competence • Collaborate Child

6. Interviewing Strategy Engaging Challenging Patients Behavioral Health Issues Developmental Functioning Physical Limitations Family Context Practice Constraints

7. Communication Skills • Reflection • Respect • Listening • Collaboration • Compassion • Verbal & nonverbal

8. Core skills in relating • Empathy – Accurate Understanding demonstrated through verbal & nonverbal means in building rapport and eliciting information through understanding. • Genuineness – congruence between verbal and non-verbal expressions, not overemphasizing roles, flexibility with roles, and spontaneity. • Positive Regard – Respect demonstrated through commitment, understanding, acceptance, and warmth.

9. Nonverbal cues in expressing warmth • Tone of voice • Facial expression • Posture • Eye contact • Touching • Gestures • Physical proximity • Synchrony of behavior with patient • Energy level

10. Effective Verbal Behaviors • Relevant & thought-provoking questions • Open ended vs closed ended questions. • Verbal attentiveness • Directness & confidence in presentation • Interpretations – careful • Concreteness • Identifying & labeling expressed feelings

11. Taking a Developmental Perspective • Infant/Child • Speaking through play/art • Modeling in the room • Inaccuracy of verbal reports • Metaphors • Adolescent • Tend to avoid direct eye-contact • Task of role differentiation • Trust & respect • Others • Be aware of limitations and review functioning with care givers. • Paper, markers, and props

12. Preschool & Primary-Age Children • Use combination of open-ended & direct questions. • Do not attempt to assume too much control over the conversation. • Gain familiarity with children’s experience & use this in developing questions. • Reduce the complexity of interview context. • Utilize props and be more in the moment. *See Hughes & Baker, 1990

13. Elementary-Age Children • Rely on familiar settings & activities. • Allow children to use props & drawings. • Avoid consistent eye contact. • Provide contextual cues – pictures, colors, examples, metaphors – along with words. *See Hughes & Baker, 1990

14. Adolescents • Be aware of their developmental task – individuation, idealism, abstract thinking, & emotions. • Direct more attention and questions. • Tend to avoid direct eye contact. • Build trust.

15. Key Elements in Interviewing • Using art work • Interviewing begins in the lobby • Parent and child – how to split time • Modeling while engaging • Always an intervention • Levels of interviewing – questions and observations • ABC • Mother who felt overwhelmed something not working • Scaling questions • Three wishes and magic question

16. Interviewing Skills in Seeking Solutions • Practitioners’ non-verbal behavior. • Echoing or asking for clarification. • Open-ended questions. • Summarizing. • Tolerating/using silence. • Noticing clients non-verbal behavior. • Self-disclosure. • Noticing process. • Complimenting. • Affirming parent’s perceptions

17. Strategies for Change

18. Terms • Consciousness Raising – A new piece of information or advice can spark curiosity or openness. • Social Liberation – Sometimes a structure in society that supports the need for change can propel people to consider change more seriously. • Helping Relationships – Any effort can be furthered by the support of others. • Emotional Arousal – Calling on emotions is an effective means of motivating the process along. • Self-re-evaluation – This is an effective process to move people towards the preparation and action stage.

19. Terms Continued… • Commitment – Saying things like “I believe I can change” or “I am willing to change” indicates a commitment. • Environmental Control – Identify places and people that may not support your plan for change and develop a strategy to work with them. • Countering – This means doing something different. Find alternative ways of approaching situations and individuals. • Reward – Identify and allow rewards after goal has been accomplished.

20. Changing Stripes…Beginning Adventures I - Ignore G – Get a Clue N – Now What? I – I am Ready! T – Try It! E - Encourage

21. Four Underlying Principles of Motivational Interviewing • Express empathy • Develop Discrepancy • Roll with resistance • Support self-efficacy *See Miller & Rollnick, 2002

22. Empathic Affirmation • Empathic understanding and responding are helpful, but those that amplify negative feelings are counterproductive. • Empathic affirmation that moves parents closer to looking at solutions is more helpful. For example: “You feel depressed and hopeless about your life” vs “I can see that things are very discouraging right now. What gives you hope that this problem can be solved?”

23. Key Tools in Seeking Solutions • Empathy • Returning the Focus to the Parent • Amplifying Solution Talk…Difference Questions

24. Amplifying Solution Talk • Encouraging parents in seeking solutions begins with parents considering what they would like to be different. • Can they even imagine situations being different? • Have parents provide as much detail as possible.

25. How to Gain Trust…Potential Blind Spots • Listening to each family member. • Demonstrating respect for family members. • Developing an understanding of the family’s past experiences, current situation, concerns, and strengths. • Responding to concrete needs quickly. • Establishing the purpose of involvement with the family. • Being aware of one’s own biases and prejudices. • Validating the participatory role of the family. • Being consistent, reliable, and honest. • Engaging and involving fathers and paternal family members

26. Engaging Parents • Tuning into self and others • Focused listening • Clarification of role and purpose • Respect • Clear and accurate response to parent questions • Honesty • Dependability • Identification and support of parent’s strengths The Pennsylvania Child Welfare Training Program

27. Engaging Parents • Seeking to understand the parent’s point of view • Culturally sensitive practice • Connecting agency goals with parent goals • Investment in parent success • Outcomes-oriented practice • Regular feedback • Confrontation • Demand for work The Pennsylvania Child Welfare Training Program

28. Returning the Focus to the Parent • Parents may tend to focus on the problem and/or what they would like others to do differently – not how agencies, schools, and others are blamed. • Try: What gives you hope that this problem can be solved? When things are going better, what will you notice you doing differently? What is it going to take to make things even a little bit better? If your close friend were here, what would they suggest for you to do to make things better? Suppose a miracle happened and the problem were solved. What is the first thing you would notice that would tell you that things were better? What would others notice?

29. Seven Key Solution-Focused Strategies • Identifying strengths in a problem situation. • Exploring past successes. • Finding and using exceptions to the problem. • Facilitating a positive vision of the future. • Scaling questions. • Encouraging commitment. • Developing action steps. The Pennsylvania Child Welfare Training Program

30. Solution-Building Questions • Tell me about the times when this problem is a little bit better? • How did you make this happen? • What else? • What are you doing differently during those times when things are a little bit better? • What would your best friend tell you when things are going a little bit better for you? The Pennsylvania Child Welfare Training Program

31. How to Gain Trust…Potential Blind Spots • Listening to each family member. • Demonstrating respect for family members. • Developing an understanding of the family’s past experiences, current situation, concerns, and strengths. • Responding to concrete needs quickly. • Establishing the purpose of involvement with the family. • Being aware of one’s own biases and prejudices. • Validating the participatory role of the family. • Being consistent, reliable, and honest. • Engaging and involving fathers and paternal family members

32. Impact & Effectiveness of Education • Oral instruction alone is not likely to be as effective as other methods. • Information handouts can be effective: • When the topic is of interest and concern. • If accompanied by a personalized oral message from the provider. • When teaching complicated sequences of skills. • Do not underestimate the impact of modeling, coaching, and role-playing. **See Glascoe, Oberklaid, Dworkin, & Trimm (1998)

33. Be Aware of…. • The “Trickiness” of verbal instructions. • It is suggested that 20% of the adult population reads below the 8th-grade level. • The agenda’s that may be in the room.

34. Myths about Child Therapy • Some argue that family therapy will fail to attend to the child’s own symptoms. • Family therapists argue that child’s symptoms indicate that family dysfunction is pathological. • Some hold that child therapy must be long term. • Young children should be excluded from family therapy. • Traumatized children will grow up to be emotionally flawed. • Children should not be included in treatment planning. • Severe and chronic behavioral difficulties will require big complex solutions. • The therapist is more of an expert on parenting.

35. Being Solution-Focused & Brief… • Begins with finding the “right” problem. • John Dewy: Any problem that is well-defined is half-solved (Parnes, 1992) • Family and child therapy techniques can compliment each other – the use of both family play and art therapy techniques. • I.e. Family house, adventure activities, grief art work. • It may be helpful to integrate Narrative Therapy ideas. • The telling and re-telling of the evolving story allows for acknowledgement of competency and empowerment. • Could implement a “Habit Control Ritual.” • Journal victories and losses over a problem and celebrate successes. **See Selekman, 1997. Solution-Focused Therapy with Children: Harnessing Family Strengths for Systemic Change

36. Thoughts on the Therapeutic Process • Again, keep a developmental perspective. • Winnicott (1971): One must have in one’s bones a theory of the emotional development of the child and the relationship of the child to the environmental factors.” • Make use of “not knowing” • Talked of a “holding environment.” • Made use of the “Squiggle Game.” • Post-modern therapist. • Reflection-in-action vs Reflection-on-action

37. Deeper Strategies • Instilling Hope. • “Building of Buffering Strengths.” • Courage. • Interpersonal skill. • Rationality. • Insight. • Optimism. • Honesty. • Perseverance. • Realism. • Capacity for pleasure. • Putting troubles into perspective. • Future mindedness. • Finding purpose. Seligman, APA Monitor, Dec. 1998

38. Building Resilience • Being empathic. • Communicating effectively & listening actively. • Changing “negative scripts.” • Loving children in ways that help them feel special & appreciated. • Accepting children for who they are & helping them set realistic expectations & goals. • Helping children experience success by identifying and reinforcing their “islands of competence.” Brooks & Goldstein, 2001

39. Building Resilience Cont…. • Helping children recognize that mistakes are experiences from which to learn. • Developing responsibility, compassion, and a social conscience by providing children with opportunities to contribute; Maintain routines. • Teaching children to solve problems & make decisions, as well as to set goals. • Disciplining in a way that promotes self-discipline. • Assist children in appreciating that change is part of life. Brooks & Goldstein, 2001

40. Tools • Gain understanding – Watch & listen • Always modeling – 3rd eye • Non-verbal’s are key • Use what you have • Props & metaphors • See pt in context – family, community, school • Keep your eye on the pt

41. Hope Theory Hope reflects an individuals’ perceptions of their capacity to: • Clearly conceptualize goals. • Develop the specific strategies to reach those goals (pathways thinking). • Initiate & sustain the motivation for using those strategies (agency thinking).

42. Hope as an Agent of Change Accentuating the determination that an individual can make improvements involves the following (in the context of relationship & community): • Hope Finding • Hope Bonding • Hope Enhancing • Hope reminding

43. Hope Finding There are three aspects in naming and measuring hope: • A personality disposition (trait) • A temporary frame of mind (state) • Hope can occur at different levels - general goals, goals in areas of life, or in specific goals.

44. Hope Bonding Building a working alliance – given that the goals of the alliance coincide with hope goal thoughts, tasks coincide with pathways, and the bond translates to agency (motivation for change).

45. Hope Bonding Continued… Building a hopeful alliance involves: • Working to establish therapeutic goals. • Generating numerous ways (pathways) to attaining goals established. • Examine how the relationship between the therapist & patient create the context/energy in which the patient can sustain effort in pursuing goals.

46. Hope Enhancing Strategies and programs that typically involve: • Conceptualize reasonable goals more clearly. • Produce numerous pathways or strategies in attaining goals. • Strengthen the energy/motivation to maintain pursuit of goals. • Reframe obstacles as challenges to be overcome. ** Making Hope Happen for Kids Program (Edwards & Lopez, 2000)

47. Narrative Approaches: G-Power G What is the character’s goal? P Which pathways does the character identify to use to move toward stated goal? O What obstacles lay in the pathway? W What source of willpower is keeping the character energized? E Which pathway did the character elect to follow? R Rethink the process – would you have made the same decisions and choices? Pedrotti, Lopez, & Krieshok, 2000

48. Hope Reminding • It is the strategy of encouraging pt’s to become their own hope-enhancing agents. • The strengthening of one’s ability to daily identify goal thoughts and barrier thoughts – increasing self-monitoring. • Development of “mini interventions” in strengthening hope.

49. Theory of Personal Control • Learned Helplessness: The giving-up reaction, the quitting response that follows from the belief that whatever you do doesn’t matter. • Explanatory Style: The manner in which you habitually explain to yourself why events happen. It is a modulator of learned helplessness. Learned Optimism: How to Change Your Mind and Your Life - Seligman

50. Guidelines for Using Optimism • Use optimism when: • You are in an achievement situation. • You are concerned in how you will feel. • The situation is apt to be protracted and your physical health is an issue. • If you want to lead, inspire others, or want people to vote for you. Learned Optimism: How to Change Your Mind and Your Life - Seligman